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FOR OFFjCE USE: "APPLICATION FOR SANITATION PERMIT --------------- - (Complete in Triplicate) Permit No. --------------------- -- ------------------------------ -0--------------------- This Permit Expires 1 Year From Date Issued Date Issued ._C."_f....._.. Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: JOB ADDRESS/LOCATION ._ c '9 -/.P. %�.----------------------------------------CENSUS TRACT --------------•--•--------- Owner's Name --- �. - - - - hone � Address ..... CitY _-_____ - ___Contractor's Name � _-_____ License # a. YIT,:�-___ Phone 3! y' Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ❑ Motel ❑Other -------------------------------------------- Number of living units:---- ----- Number of bedrooms 7------__G''arbage Grinder ________--_ Lot Size __ _ __ :_ -------- Water Supply: Public System and name ------------------ --____-, - W -------------------------•_-.----------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ,❑ Clay Loam ;❑ Hardpan ❑ AdobeX Fill Material ------------ If yes,type -__._______________________ (i (Plot plan, showing size of lot, location of system in relation to wells, buildings, etc. must be placed on reverse side.) W NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200 feet,) PACKAGE TREATMENT [ ] SEPTIC TANK'[ ] Size----------------------------------- __________ Liquid Depth ----__-____--------_.--___ W Capacity ------------------- Type -------------------- Material---------------------- No. Compartments ...................... Distance to nearest: Well _________________________________Foundation ---------------------- Prop. Line ...................... LEACHING LINE [ ] No. of Lines _________ Length of each line---------------------------- Total Length ,.......... ................ 'D' Box ____________ Type Filter Material ____________________Depth Filter Material --____--____________.__------------_...__.-- Distance to nearest: Well ________________________ Foundation -------------------- --- Property Line ________-.__--_-..._..-- SEEPAGE PIT [ ] Depth -------------------- Dieter ________________ Number ---------------------------- Rock Filled Yes '❑ No 0 Water Table Depth ---- -----------------------------------------Rock Size -------------------------------- Distance to nearest: Well ________________________________________Foundation -------------------- Prop. Line ...................... REPAIR/ADDITION(Prev. Sanitation Permits# -------------------------------------------- Date ___________________._________--.__) Septic Tank (Specify Requirements) ---- - Disposal Field (Specify Requirements) ---- `Q V _______________________._-_ -- -- --- --- - - ----_--------------------- V'-------� - --------- -------------------- 10 ----------- ------ 1 ,► _< (Draw existing and ddition on 2rse side require- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, 1 shall not employ any person in such manner as to b e `ubpq to,Wor an's Compensation laws of California." Signed -. - ""e-1""'---------------------- Owner ;' A ---------------------------------------------------- Title ------------ ---------------------------------------------------------- (If other thfowner) FO DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- - - --- ------ G�!_ ---------------------------------- DATE ------- � 7- -,a----- BUILDING PERMIT ISSUED ------------------------------------ ------ ---------------DATE ------------- ---------------- ADDITIONALCOMMENTS ---------------------------------------------------------- -----------------------------------------------------------------------=--------------------------- ------------- ------------------------------------------ --------- ------------------------------------------------------------------------------------ ----------------------------- ---------- --------------------------------------------------------- - - - - -- -- ----------- - - - - - - - - - - - - - - ------------- --------------------- --- - -- ------ - ---- - --------- -- - - -- - Final Inspection by: __ __ _ ___-__-_ _ _ Date -______-_ _ ----------------------------------- ----------------------------- -- ------- SKIN JOAQUIN LOCAL HEALTH DISTRICT E. H. 9 1-'68 Rev. 5M